E-Health: Opportunity or Threat to the medical library profession.

Josephine Marshall
The Walter and Eliza Hall Institute of Medical Research - Royal Melbourne Hospital
Post Office - 3050 Victoria (Australia)

Click here to see the ppt presentation



In a 1999 Australian Government report, "The unstoppable rise of E-health", e-health was defined as "The use in the health sector of digital data for clinical, educational and administrative purposes". 1

The proliferation throughout the world of both commercial and government e-health initiatives offering information direct to the medical profession can be seen as both a threat and an opportunity for our profession. Today I will discuss how these initiatives are impacting on us at present , how they are being discussed in the professional and business literature and suggest ways that we as a profession should react to such developments.

What really is e-health? Is it hype or is it a viable new information business?At a conference in Australia in September 2000 academics and leading health experts agreed that greater use of electronic health technologies could hold the key to reducing the estimated 14,000 avoidable hospital deaths in Australia each year and that the internet was the key to providing hospital staff with information.2 Such outcomes would be greeted with astonishment by health librarians who traditionally have been the providers of information access. What have we been doing to allow ourselves to be left out of the information loop in health? More of that later.

E-health was promoted as the nirvana of the e commerce world throughout 1999 and the first half of 2000. The huge investments in the USA in companies such as Healtheon, WebMD, DrKoop and Medscape were seen as a lucrative option for venture capitalists. Investors could not get enough of such e-health companies which professed to go beyond popular established information sites and change the nature of medical communication, restructure global healthcare systems and even save lives! High ambitions indeed. Doctors themselves were , it seemed, not desperate to take up these offers and as had happened with so many internet based companies Wall Street pulled the plug on the e-health boom. The pace of dot.com failures quickened and in mid 2000 we saw a rush of mergers and acquisitions as companies desperately bid for survival. What we have at the moment amongst those companies left is a realisation that they must concentrate on attracting the medical profession to use the internet and to address content issues of their sites. Surely we librarians could have told them that if they had asked us or in fact, if we had been involved at all! I wonder how many of these companies employed librarians or even sought their opinion on how doctors traditionally accessed information? In an article in Hospital and Health Networks in January 2000 entitled "docs.com" Michael Menduno states that the doctor desktop is largely a misnomer. Most doctors still do not use computers in daily operations. When companies talk about connecting doctors they are actually referring to the practice staff who do use computers in daily operations. He quotes a recent poll which showed that 87% of doctors surveyed surfed the internet but only 40% of that use was in conjunction with medical practice.3 A WebsurveyMD.com survey in July 2000 confirms that in spite of the vast amounts of money invested in e-health physicians still under utilise the internet, have little interest, other than for basic informational uses and are indeed sceptical about the benefit of the internet to healthcare.4

In an e.MD Online article in Fall 2000 Dr Lyle Berkowitz evaluated what he considered the top 5 Physician Web portals- MD Consult, Medscape, WebMD, Doctor's Guide and Physician's Online and concluded that there are problems for doctors in conquering the information overload. Firstly there is a need to increase comfort levels with the internet, secondly companies need to create valuable web sites, sites that are intuitive and support both the administrative and information functions of the doctor's practice, and thirdly and most importantly doctors need to learn how to find the most beneficial and functional sites to support particular needs. Surely there is an opportunity here for we librarians!5 In a provocative article in the New York Times in October 2000 Dr Abigail Zuger posed the question-has the web made a difference? She says that practising medicine on the Web is as dangerous and addictive a habit for doctors as for anyone else.6 Her comments on " trudging over to the library" generated much discussion on that excellent list serve MEDLIB-L. Some librarians immediately took umbrage at the intent of the article but in the end it was T. Scott Plutchak who commented that the bottom line of the article was that" It is not all on the internet and it's is not all free-who can argue with that".7 In actual fact the article was rather positive, factually correct as to how medical information is used today, and better still was in the recognised world media.

Dr Davidoff in the Annals of Internal Medicine June 2000, in a much discussed editorial, "The Informationist a New Profession" discusses the complications involved in medical literature retrieval. He suggests that we should face up to the fact that doctors cannot and should not try to do all or even the most basic information searches themselves and suggests the need for a new professional based on the previous model of clinical librarianship to train and be experts in handling meta information. Such a professional would play a crucial role in improving existing information retrieval systems and creating new ones of value.8 Is this the future? Why did so many librarians get so angry with the suggestion? This would appear to me to be a positive extension of our current role and provide an ideal link between the current medical librarian and e-health companies. Is the situation that in our traditional role we do not understand the methods employed by the e commerce world? After all we are familiar with the longstanding values concerning access to and management and preservation of information and knowledge resources. Suddenly when the paradigm shift ocuurs and information becomes a commodity to be traded and valued the stakes in ownership are raised dramatically.Librarians in all countries are more involved with government e-health initiatives. Do we feel more comfortable at this level rather than the high tech big business end of the spectrum? I suspect so. After all the majority of us are employed in government hospitals, government funded or supported academic institutions or the research sector.

Currently in Australia librarians are desperately trying, if not belatedly, to stake their claim in government e-health projects. In October 2000 "Netting a Nation of Physicians-National Health Knowledge Summit Resource Forum" was held in Sydney.9 This was a milestone in our country because of the multidisciplinary background of its participants, including a number of librarians, and its focus on health knowledge resources. The health data and information continuum was discussed in detail. Librarians have been working at the knowledge end of this continum for many decades. Often under funded and under appreciated libraries are struggling to find their place in the changing industry. After all we have always taken up the challenges of the new technologies rapidly but always within the constraints of our budgets and the consumer driven demands to maintain our legacy of paper libraries.

The e-health boom (or bust depending on one's opinion) has attracted the attention of other groups in the health sector but why not librarians? Clinicians and health managers seeking a change of career are reinventing themselves as health informatics/information experts. E-health initiatives in Australia such as the Clinical Information Access Project (CIAP) have been very successful because they have provided an opportunity for access to health resources remotely, away from the traditional physical site of such resources, our libraries. CIAP is an interesting model when thinking of threats to the way we operate as a profession. The style of the CIAP project simply aggregates concurrent users for Web based access through a single gateway to resources that we already provide within our libraries or local networks. That is the core medical bibliographic databases, drug information tools, texts and ejournals. Such developments on a wide scale require money, power and staff time, all which are in short supply in health libraries and their networks. With such government sponsored initiatives the big question will be how will this impact on individual library budgets. One can hardly blame a participating hospital for cutting funds to the library when they can access the information through the centralised source without overhead costs. The motto of CIAP is "For Physicians, By Physicians". A threat indeed.10

This year the national government of Australia is developing Health Online: A health information action plan for Australia.11 This plan was formulated by the National Health Information Management Advisory Council, and as you may guess, no librarian was represented on the initial panel. I am pleased to report that the national group of Australian health librarians has made a submission to the plan. This is a positive step. Thanks to the efforts of a group of committed individuals from around Australia we now have a detailed report of what we as a profession can offer as well as articulating the current practice of health librarianship in our country.

After all we know that health librarians have the education and experience to provide expert advice to the project. We have a working knowledge of the depth and breadth of health information as well as empirical experience in meeting the information needs of health professionals and consumers. An important point is that libraries are one of the few collaborative components of the health system. In Australia there are well developed national collaborative library systems. In recent years Australian health librarians have been key stakeholders in the development and management of a number of state based projects in health information access but need to be included in strategic planning on a national basis.While recognising the way health libraries function is now adequate the submission recognises that those ways need to change to make the very best use of technology to deliver services. The National/State health infrastructure to date has not supported the achievement of national priority setting for health libraries nor the implementation of cooperative library practice. The submission recognises that while some important and useful state based projects as CIAP that I mentioned before, provide access to a core of web based services it is not possible economically for such projects to offer the depth of resources available from libraries. After all health libraries contain the research literature which underpins the evidence needed to support improved clinical decision making. Health librarians are well on the way in the transition from paper based collections to providing access to web based resources and all that that entails: web page creation with specialised knowledge of the appropriate context architecture, purchasing and licensing resources, cataloguing(metadata), teaching skills in using and navigating through the technology. The submission address specific goals in the Health Online policy and elaborates on contributions by librarians. It is valuable to look at these in detail as they are appropriate for creating opportunities for us all at a global level.

"Develop national standards for health information management and IT that are compatible with international standards activity"

Health librarians have experience in and knowledge of health information management and IT. Library automation software which uses MARC and use of Z39.50 protocol was some of the earliest software to adopt international standards. The importance of data structures in electronic environments have been recognised and dealt with by librarians for many years.

"Training and support for health care workers and consumers to encourage uptake and use of information technology"

Health librarians currently provide training and support to health care workers in the use of IT and information resources. This role is increasing due to librarian's enthusiasm for improving health workers skills for evidenced based practice, defining a clinical question, searching the literature, critical appraisal of the literature, application of information to patient care , evaluation of the outcome.

"Foster research development and best practice in the use and implementation of online technologies in the health sector"

Librarians have been at the forefront of the push to create networked information systems. We can help by providing information and data for research in this area. Specific libraries could be studied in trials to evaluate the use, implementation, and effectiveness of online technologies, particularly relating to health outcomes.

"Expand development of decision support services"

Librarians have considerable experience in providing these services with traditional media and understanding the needs of clinicians. Moving the resources to the clinical environment and integrating them with other clinical systems is the next logical step. Health libraries could be used to develop , test and evaluate services. Appropriate structures for the best organisation and delivery of information are an important determinant of take up and use by clinicians in practice.

"Increased use of online applications to support efficient clinical practice"

The amount of information that can currently be delivered to the point of care is extensive. Decision support information, radiology images, test results, prescription resources, clincal pathways and guidelines, clinical alerts, patient records, referrals and so on. It will be the structure and organisation that will determine the useability in practice of this potential information overload.

"Expand markets for Australian online health services"

Australian health librarians have active connections with their international counterparts to contribute to the expansion of markets. Initiatives in Australia such as this go a long way to promoting what we can do as a profession to be of value in the e-health sector. For years we have been articulating our role very well within our profession but we still seem to lack the confidence to articulate our values to the wider information community. As key stakeholders in the field we must ensure that we are among the key industry groups and leaders who provide leadership in the promotion of and strategic direction for e-health. In an article in Online November 2000 with the provocative title "The revenge of the librarian" the authors state that " business professionals would be surprised at just how suited librarians are to the dot.com world"12. This century will assuredly be the knowledge century. In a largely borderless, highly derugulated, harshly competitive and internet-linked world knowledge skills and technologies will be the new currencies. We as a profession are ideally placed to take up the challenge of e-health, be proactive and grasp the opportunity to use our specialist talents .


1. From Telehealth to E-Health: The unstoppable Rise of E-Health. Australia, Commonwealth Department of Communications, Information Technology and The Arts, National Office of the Information Economy, 1999

2. New South Wales Department of Health. Netting a Nation. of Clinicians: National Summit Knowledge Forum, 26-27 October 2000
3. Menduno M. docs.com. Hospital and Health Networks 2000;74:51-54,56.
4. Update on Physicians and the Internet. A WebsurveyMS.com Survey. [Press release]
http://www.websurveyMD.com , 2000
5. Berkowitz L. 5 portals that shine. e.MD Online Fall 2000
6. Zuger A. Reams of information, some of it even useful. New York Times October 25,2000
7. Plutchak T S. New York Times E-Commerce today. [message] MEDLIB-L Discussion List October 25, 2000
8. Davidoff F, Florance V. The informationist: a new health profession? Annals of Internal Medicine 2000; 132: 996-8
9. New South Wales Department of Health Netting a Nation of Clinicians: National Summit Knowledge Forum, 26-27 October 2000
10. Clinical Information Access Project. CIAPP
11. Australia.National Health Information Management Advisory Council. Health Online: A health information action plan for Australia.
12. Ainsbury B Futornick M. The revenge of the library scientist. Online Nov 2000